DESCRIPTION: Recent research suggests that Medicare hospice care provides important benefits to dying nursing home (NH) residents. Research shows hospice enrollment is associated with greater probability of residents having their pain assessed and managed with a lesser probability of being hospitalized at the end-of-life. However, enrollment in Medicare hospice is not available to all NH residents. NH residents can only elect hospice if a NH has a contract with a hospice provider, and in practice, not all NHs have such contracts. Furthermore, not all NH residents with access to hospice choose the benefit and incentives of the NH and hospice providers will likely influence this decision. An understanding of how this double-layer selection process functions is essential to understanding access to hospice in NHs and to developing statistical and economic modes that most fully consider selection biases. In this proposed project Dr. Gozalo will examine the process by which the Medicare hospice benefit becomes available to terminally ill NH residents, and when available, the process by which the residents select the benefit. He proposes a model of endogenous decision making that takes advantage of a rich longitudinal data set linking Medicare claims, nursing home and hospice providers data and Minimum Data Set (MDS) clinical information in the state of Ohio. The study aims are: (1) measure the effects of nursing homes, hospice providers and market characteristics on the availability of hospice in nursing homes, and (2) Measure the effects of patient, nursing home and hospice provider characteristics on the election of Medicare hospice benefit by eligible nursing home patients. The model and data emanating from this study will be used in the development of an R01 proposal to be submitted at the end of the project period. This project, and subsequent work, will be important to policymakers for monitoring hospice care provision and for deciding on future changes in the administration of the Medicare hospice benefit.